BUKO PIE ORDER FORM Confirmation requires the form below t o be completed in its entirety though a different form of payment is acceptable at the time of pick up Size Price Each Qty Total BUKO PI ID: 826688
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BUKO PIE ORDER FORM Pie orders m
BUKO PIE ORDER FORM Pie orders must be confirmed at least 48 hours before desired pick up time. Confirmation requires the form below to be completed in its entirety, though a different form of payment is acceptable at the time of pick up. Size Price (Each) Qty Total BUKO PIE young coconut, coconut cream, streusel 8” pie 6 slices $36 PAYMENT INFORMATION CARD TYPE: ___ VISA ___ AMEX ___ MASTERCARD NAME: __________________________________________________________________________________________ (as it appears on card) BILLING ADDRESS: __________________________________________________________________________________________ CARD NUMBER: ________________________________________________________________________ EXPIRATION DATE: ________________ SECURITY CODE: ________________ CONTACT TELEPHONE: _________________________________________________________ SIGNATURE: __________________________________________________________________________________________ I, the above signed, certify that all the information is complete and accurate. I hereby authorize Sprout GCM, LLC to collect payment for all the charges indicated herein, including sales tax, by processing a charge to the credit card listed above. I certify that I am the authorized signer of the credit card listed above. A 4% charge will be added to your check to help cover the cost of health care benefits we offer to our full-time employees. Thank you for supporting our staff. If you would like this 4% charge removed, please let us know. PICK UP INFORMATION PICK UP DATE: ________________ PICK UP TIME: ________________ ORDER TAKEN BY: ______________________